Respiratory sounds. Advances beyond the stethoscope

Validity and reliability of acoustic analysis of respiratory sounds in infants

OBJECTIVE

To investigate the validity and reliability of computerised acoustic analysis in the detection of abnormal respiratory noises in infants.

METHODS

Blinded, prospective comparison of acoustic analysis with stethoscope examination. Validity and reliability of acoustic analysis were assessed by calculating the degree of observer agreement using the kappa statistic with 95% confidence intervals (CI).

RESULTS

102 infants under 18 months were recruited. Convergent validity for agreement between stethoscope examination and acoustic analysis was poor for wheeze (kappa = 0.07 (95% CI, -0.13 to 0.26)) and rattles (kappa = 0.11 (-0.05 to 0.27)) and fair for crackles (kappa = 0.36 (0.18 to 0.54)). Both the stethoscope and acoustic analysis distinguished well between sounds (discriminant validity). Agreement between observers for the presence of wheeze was poor for both stethoscope examination and acoustic analysis. Agreement for rattles was moderate for the stethoscope but poor for acoustic analysis. Agreement for crackles was moderate using both techniques. Within-observer reliability for all sounds using acoustic analysis was moderate to good.

CONCLUSIONS

The stethoscope is unreliable for assessing respiratory sounds in infants. This has important implications for its use as a diagnostic tool for lung disorders in infants, and confirms that it cannot be used as a gold standard. Because of the unreliability of the stethoscope, the validity of acoustic analysis could not be demonstrated, although it could discriminate between sounds well and showed good within-observer reliability. For acoustic analysis, targeted training and the development of computerised pattern recognition systems may improve reliability so that it can be used in clinical practice.

Respiratory acoustic thoracic imaging (RATHI): Assessing deterministic interpolation techniques

As respiratory sounds contain mechanical and clinical pulmonary information, technical efforts have been devoted during the past decades to analysing, processing and visualising them. The aim of this work was to evaluate deterministic interpolating functions to generate surface respiratory acoustic thoracic images (RATHIs), based on multiple acoustic sensors. Lung sounds were acquired from healthy subjects through a 5 x 5 microphone array on the anterior and posterior thoracic surfaces. The performance of five interpolating functions, including the linear, cubic spline, Hermite, Lagrange and nearest neighbour method, were evaluated to produce images of lung sound intensity during both breathing phases, at low (approximately 0.5ls(-1)) and high (approximately 1.0ls(-1)) airflows. Performance indexes included the normalised residual variance nrv (i.e. inaccuracy), the prediction covariance cv (i.e. precision), the residual covariance rcv (i.e. bias) and the maximum squared residual error semax (i.e. tolerance). Among the tested interpolating functions and in all experimental conditions, the Hermite function (nrv=0.146 +/- 0.059, cv= 0.925 +/- 0.030, rcv = -0.073 +/- 0.068, semax = 0.005 +/- 0.004) globally provided the indexes closest to the optimum, whereas the nearest neighbour (nrv=0.339 +/- 0.023, cv = 0.870 +/- 0.033, rcv= 0.298 +/- 0.032, semax = 0.007 +/- 0.005) and the Lagrange methods (nrv = 0.287 +/- 0.148, cv = 0.880 +/- 0.039, rcv = -0.524 +/- 0.135, semax = 0.007 +/- 0.0001) presented the poorest statistical measurements. It is concluded that, although deterministic interpolation functions indicate different performances among tested techniques, the Hermite interpolation function presents a more confident deterministic interpolation for depicting surface-type RATHI.

Acoustic evidence of airway opening during recruitment in excised dog lungs

The aim of this study was to test the hypothesis that the mechanism of recruitment and the lower knee of the pressure-volume curve in the normal lung are primarily determined by airway reopenings via avalanches rather than simple alveolar recruitments. In isolated dog lung lobes, the pressure-volume loops were measured, and crackle sounds were recorded intrabronchially during both the first inflation from the collapsed state to total lobe capacity and a second inflation without prior degassing. The inflation flow contained transients that were accompanied by a series of crackles. Discrete volume increments were estimated from the flow transients, and the energy levels of the corresponding crackles were calculated from the sound recordings. Crackles were concentrated in the early phase of inflation, with the cumulative energy exceeding 90% of its final value by the lower knee of the pressure-volume curve. The values of volume increments were correlated with crackle energy during the flow transient for both the first and the second inflations ( r2 = 0.29–0.73 and 0.68–0.82, respectively). Because the distribution of volume increments followed a power law, the correlation between crackle energy and discrete volume increments suggests that an avalanche-like airway opening process governs the recruitment of collapsed normal lungs.

Histamine induced airway response in pre-school children assessed by a non-invasive EMG technique

The aim of the study was to investigate the association between surface electromyographic (EMG) activity of the diaphragm and intercostal muscles, and clinical symptoms (wheeze, cough, increased respiratory rate and prolonged expiration) during bronchial challenge testing and after administration of salbutamol in asthmatic pre-school children. A histamine challenge test was performed in 20 asthmatic pre-school children. The histamine dose at the appearance of 1 or more clinical symptoms was defined as the maximum histamine provocation dose (PDcs). The clinical symptoms were recorded with a microphone over the trachea. The logarithm of the EMG-Activity-Ratio (log EMGAR; mean peak activity ratio to baseline of respiratory muscles during tidal breathing) was used as EMG parameter. In both the diaphragmatic and the intercostal log EMGAR values a linear increase was observed in the four histamine dose-steps prior to PDcs. At PDcs the mean log EMGAR of the diaphragm (di) and intercostal muscles (int) was significantly increased as compared to the baseline values. After administration of salbutamol the log EMGARdi and log EMGARint returned to baseline values and the clinical symptoms normalized in all children. At PDcs, no significant differences in the log EMGAR values could be detected at the appearance of the distinctive clinical symptoms, which suggests that wheezing is not the only indicator for the detection of airway responsiveness in young children. We found a linear association between histamine dose and the increase in surface diaphragmatic and intercostal respiratory EMG activity during a bronchial challenge test in pre-school asthmatic children, which returned to baseline values after inhalation of salbutamol. These findings support the idea that EMG measurements of the diaphragm and intercostal muscles may offer an opportunity to estimate airway response in young children in an alternative way.

Time-frequency detection and analysis of wheezes during forced exhalation

The objective of the present work was to detect and analyze wheezes by means of a highly sensitive time-frequency algorithm. Automatic measurements were compared with clinical auscultation for forced exhalation segments from 1.2 to 0 liters/second (l/s). Sensitivities between 100% and 71%, as a function of flow level related to wheezing segments detection, were achieved. Time-frequency wheeze parameters were measured for the flow range from 1.2 to 0.2 l/s. Wheezes were detected in both analyzed groups; asthmatics (N = 16) and control subjects (N = 15). Significant differences between groups were found for the mean number of wheezes detected at basal condition (p = 0.0003). Frequency parameter differences were also significant (0.0112 < p < 0.0307). All these parameters were also studied after applying a bronchodilator drug (Terbutaline). Significant differences between patient groups were found when studying the changes in the number of wheezes for each patient (p = 0.0195). Finally, limited bandwidth parameters, which measure the bronchodilator response, were also studied.

A high resolution computer model for sound propagation in the human thorax based on the Visible Human data set

A parallel supercomputer model based on realistic tissue data is developed for sound propagation in the human thorax and the sound propagation behavior is analyzed under various conditions using artificial sound sources. The model uses the Visible Human male data set for a realistic representation of the human thorax. The results were analyzed in time and frequency domains. The analysis suggests that lower frequencies of around 100 Hz are more effectively transmitted through the thorax and that the spatial confinement of sound waves within the thorax results in a resonance effect at around 1500 Hz. The results confirm previous studies that show the size of the thorax plays a significant role in the type of sound generated at the chest wall.

Tracheal and lung sounds repeatability in normal adults

Tracheal and lung sounds measurements for clinical applications depends on their intrasubject repeatability. Our objectives were to characterize tracheal and lung sounds and to investigate the temporal variability in normal adults. Tracheal sounds were studied in 7 subjects and lung sounds in 10 adults. Acoustic measurements were done in five occasions over a month for tracheal sounds and on seven occasions over a year for lung sounds. Sounds were recorded using contact sensors on the suprasternal notch and on the posterior right lower lobe. Subjects breathed through a pneumotachograph at flows of 0.9-1.1 l/s. Signals were low-pass filtered, amplified and Fourier analysis was applied to sounds within a target flow range. We measured the frequencies below which 25% (F25), 50% (F median), 75% (F75) and 99% (SEF99) of the spectral power between 100 and 2000 Hz. There were no differences between the measurements obtained at different days comparing each subject (P = ns, ANOVA). Our results show that the spectral pattern of tracheal and lung sounds are stable with low intrasubject variability.

Pulmonary assessment: what you need to know

The purpose of this review is to describe a step-by-step assessment of the pulmonary system. Beginning with the sequence of the history and physical examination related to pulmonary assessment, the author describes the most common chief complaints and potential causes of these symptoms. The inspection, palpation, percussion, and auscultation steps of the physical examination are also reviewed. A detailed assessment of the pulmonary system will aid in the identification of patient problems and assist in the selection of appropriate goals and interventions for the patient.

Perimeter growth of a branched structure: application to crackle sounds in the lung

We study an invasion percolation process on Cayley trees and find that the dynamics of perimeter growth is strongly dependent on the nature of the invasion process, as well as on the underlying tree structure. We apply this process to model the inflation of the lung in the airway tree, where crackling sounds are generated when airways open. We define the perimeter as the interface between the closed and opened regions of the lung. In this context we find that the distribution of time intervals between consecutive openings is a power law with an exponent beta approximately 2. We generalize the binary structure of the lung to a Cayley tree with a coordination number Z between 2 and 4. For Z=4, beta remains close to 2, while for a chain, Z=2 and beta=1, exactly. We also find a mean field solution of the model.

Spectral analysis of respiratory noise in horses with upper airway disorders

REASONS FOR PERFORMING STUDY

It has long been recognised that the production of abnormal respiratory sounds by horses during exercise is frequently associated with upper airway obstructions. Respiratory acoustic measurements have shown promise in investigation of upper airway disorders in man and, more recently, in horses with experimentally-induced obstructions.

OBJECTIVES

To evaluate sounds from exercising horses with naturally occurring dynamic obstructions of the upper respiratory tract and to compare these with those from normal horses in order to determine whether different obstructions produce characteristic spectral patterns.

METHODS

The audio signal, airflow and videoendoscopic images were recorded simultaneously during an incremental exercise test on a high-speed treadmill.

RESULTS

Spectral analysis of the audio signal showed marked differences between control and clinically afflicted horses. Dorsal displacement of the soft palate was characterised by a narrow low frequency (20-80 Hz) peak during expiration. Horses with dynamic laryngeal collapse produced inspiratory sounds characterised by a broad band high frequency spectral component in the range 1.1-2.7 kHz.

CONCLUSIONS AND POTENTIAL RELEVANCE

Spectral analysis of respiratory sounds in horses has potential as a diagnostic technique for field use especially when facilities for high-speed treadmill assessment are not practicable.

Surface response of a viscoelastic medium to subsurface acoustic sources with application to medical diagnosis

The response at the surface of an isotropic viscoelastic medium to buried fundamental acoustic sources is studied theoretically, computationally and experimentally. Finite and infinitesimal monopole and dipole sources within the low audible frequency range (40-400 Hz) are considered. Analytical and numerical integral solutions that account for compression, shear and surface wave response to the buried sources are formulated and compared with numerical finite element simulations and experimental studies on finite dimension phantom models. It is found that at low audible frequencies, compression and shear wave propagation from point sources can both be significant, with shear wave effects becoming less significant as frequency increases. Additionally, it is shown that simple closed-form analytical approximations based on an infinite medium model agree well with numerically obtained "exact" half-space solutions for the frequency range and material of interest in this study. The focus here is on developing a better understanding of how biological soft tissue affects the transmission of vibro-acoustic energy from biological acoustic sources below the skin surface, whose typical spectral content is in the low audible frequency range. Examples include sound radiated from pulmonary, gastro-intestinal and cardiovascular system functions, such as breath sounds, bowel sounds and vascular bruits, respectively.

Pulmonary impairment and disability

Respiratory disorders, including occupational and environmental lung diseases, are prevalent. Physicians are frequently called upon to determine impairment and aid in the assessment of disability caused by these conditions, either as the treating physician or as an independent medical examiner. In this article we reviewed the role of physicians in determining the presence and severity of pulmonary disorders. A comprehensive clinical assessment and appropriate standardized tests, to objectively characterize the severity of impairment, are the key elements of the evaluation. This assessment may also include the physician's opinion regarding causative factors. Finally, disability determination is made by nonclinicians, through administrative means, based on the degree of impairment and a review of circumstances specific to the individual. Knowledge of these components of disability evaluation will help physicians to better serve their patients and supply appropriate data to the adjudicating system.

Phonospirometry for noninvasive measurement of ventilation: methodology and preliminary results

We measured tracheal flow from tracheal sounds to estimate tidal volume, minute ventilation (VI), respiratory frequency, mean inspiratory flow (VT/TI), and duty cycle (TI/Ttot). In 11 normal subjects, 3 patients with unstable airway obstruction, and 3 stable asthmatic patients, we measured tracheal sounds and flow twice: first to derive flow-sound relationships and second to obtain flow-volume relationships from the sound signal. The flow-volume relationship was compared with pneumotach-derived volume. When subjects were seated, facing forward and with neck rotation, flexion, and standing, flow-volume relationship was within 15% of pneumotach-derived volume. Error increased with neck extension and while supine. We then measured ventilation without mouthpiece or nose clip from tracheal sounds during quiet breathing for up to 30 min. Normal results +/- SD revealed tidal volume = 0.37 +/- 0.065 liter, respiratory frequency = 19.3 +/- 3.5 breaths/min, VI = 6.9 +/- 1.2 l/min, VT/TI = 0.31 +/- 0.06 l/s, and TI/Ttot = 0.37 +/- 0.04. Unstable airway obstruction had large VI due to increased VT/TI. With the exception of TI/Ttot, variations in ventilatory parameters were closer to log normal than normal distributions and tended to be greater in patients. We conclude that phonospirometry measures ventilation reasonably accurately without mouthpiece, nose clip, or rigid postural constraints.

Volume-dependent variations of regional lung sound, amplitude, and phase

Acoustic imaging of the respiratory system demonstrates regional changes of lung sounds that correspond to pulmonary ventilation. We investigated volume-dependent variations of lung sound phase and amplitude between two closely spaced sensors in five adults. Lung sounds were recorded at the posterior right upper, right lower, and left lower lobes during targeted breathing (1.2 +/- 0.2 l/s; volume = 20-50 and 50-80% of vital capacity) and passive sound transmission (< or =0.2 l/s; volumes as above). Average sound amplitudes were obtained after band-pass filtering to 75-150, 150-300, and 300-600 Hz. Cross correlation established the phase relation of sound between sensors. Volume-dependent variations in phase (< or =1.5 ms) and amplitude (< or =11 dB) were observed at the lower lobes in the 150- to 300-Hz band. During inspiration, increasing delay and amplitude of sound at the caudal relative to the cranial sensor were also observed during passive transmission in several subjects. This previously unrecognized behavior of lung sounds over short distances might reflect spatial variations of airways and diaphragms during breathing.

Pneumothorax detection using computerised analysis of breath sounds

The primary objective of the study was to investigate the effects of pneumothorax (PTX) on breath sounds and to evaluate their use for PTX diagnosis. The underlying hypothesis is that there are diagnostic breath sound changes with PTX. An animal model was created in which breath sounds of eight mongrel dogs were acquired and analysed for both normal and PTX states. The results suggested that pneumothorax was associated with a reduction in sound amplitude, a preferential decrease in high-frequency acoustic components and a reduction in sound amplitude variation during the respiration cycle (p<0.01 for each, using the Wilcoxson signed-rank test). Although the use of diminished sound amplitude for PTX diagnosis assumes availability of baseline measurements, this appears unnecessary for high-frequency reduction or sound amplitude changes over the respiratory cycle. Further studies are warranted to test the clinical feasibility of the method in humans.

Detection of porcine oleic acid-induced acute lung injury using pulmonary acoustics

To evaluate the utility of monitoring the sound-filtering characteristics of the respiratory system in the assessment of acute lung injury (ALI), we injected a multifrequency broadband sound signal into the airway of five anesthetized, intubated pigs, while recording transmitted sound over the trachea and on the chest wall. Oleic acid injections effected a severe lung injury predominantly in the dependent lung regions, increasing venous admixture from 6 +/- 1 to 54 +/- 8% (P < 0.05) and reducing dynamic respiratory system compliance from 19 +/- 0 to 12 +/- 2 ml/cmH(2)O (P < 0.05). A two- to fivefold increase in sound transfer function amplitude was seen in the dependent (P < 0.05) and lateral (P < 0.05) lung regions; no change occurred in the nondependent areas. High within-subject correlations were found between the changes in dependent lung sound transmission and venous admixture (r = 0.82 +/- 0.07; range 0.74-0.90) and dynamic compliance (r = -0.87 +/- 0.05; -0.80 to -0.93). Our results indicate that the acoustic changes associated with oleic acid-induced lung injury allow monitoring of its severity and distribution.

Detection of bronchial breathing caused by pneumonia

The classic auscultation with stethoscope is the established clinical method for the detection of lung diseases. The interpretation of the sounds depends on the experience of the investigating physician. Therefore, a new computer-based method has been developed to classify breath sounds from digital lung sound recordings. Lung sounds of 11 patients with one-sided pneumonia and bronchial breathing were recorded on both the pneumonia side and on contralateral healthy side simultaneously using two microphones. The spectral power for the 300-600 Hz frequency band was computed for four respiratory cycles and normalized. For each breath, the ratio R between the time-segments (duration = 0.1 s) with the highest inspiratory and highest expiratory flow was calculated and averaged. We found significant differences in R between the pneumonia side (R = 1.4 +/- 1.3) and the healthy side (R = 0.5 +/- 0.5; p = 0.003 Wilcoxon-test) of lung. In 218 healthy volunteers we found R = 0.3 +/- 0.2 as a reference-value. The differences of ratio R (delta R) between the pneumonia side and the healthy side (delta R = 1.0 +/- 0.9) were significantly higher compared to follow-up studies after recovery (delta R = 0.0 +/- 0.1, p = 0.005 Wilcoxon-test). The computer based detection of bronchial breathing can be considered useful as part of a quantitative monitoring of patients at risk to develop pneumonia.

'Slide whistle' breath sounds: acoustical correlates of variable tracheal obstruction

We report a case of a man who developed severe shortness of breath and the finding of breath sounds that rose in frequency during inspiration and fell during expiration. These unusual sounds were caused by a spherical tumour arising from the main carina that nearly completely obstructed the distal trachea. The frequency variation disappeared after the removal of the mass. We evaluated this phenomenon using a modelling technique that we had previously developed to analyse the human airways as acoustical tubes. This analysis revealed that the acoustical conditions in the trachea were substantially modified by the presence of the solid mass as the trachea slightly dilated during inspiration, partially relieving the obstruction. Most of the anomalous characteristics of the breath sounds could be explained using this model. We conclude that a detailed understanding of the acoustic conditions of the airways allows correlation with anatomical and physiological conditions and may be of use in diagnosis or evaluation of the airways in health and disease.

Modeling sound transmission through the pulmonary system and chest with application to diagnosis of a collapsed lung

A theoretical and experimental study was undertaken to examine the feasibility of using audible-frequency vibro-acoustic waves for diagnosis of pneumothorax, a collapsed lung. The hypothesis was that the acoustic response of the chest to external excitation would change with this condition. In experimental canine studies, external acoustic energy was introduced into the trachea via an endotracheal tube. For the control (nonpneumothorax) state, it is hypothesized that sound waves primarily travel through the airways, couple to the lung parenchyma, and then are transmitted directly to the chest wall. In contradistinction, when a pneumothorax is present the intervening air presents an added barrier to efficient acoustic energy transfer. Theoretical models of sound transmission through the pulmonary system and chest region to the chest wall surface are developed to more clearly understand the mechanisms of intensity loss when a pneumothorax is present, relative to a baseline case. These models predict significant decreases in acoustic transmission strength when a pneumothorax is present, in qualitative agreement with experimental measurements. Development of the models, their extension via finite element analysis, and comparisons with experimental canine studies are reviewed.

Disturbances in airflow dynamics and tracheal sounds during forced and quiet breathing in subjects with unilateral vocal fold paralysis

Variable extra thoracic obstruction has been found in spirometric studies in subjects with unilateral vocal fold paralysis. The aim of the study was to further evaluate airflow dynamics in these subjects with body plethysmography and tracheal sound analysis. Ten patients with unilateral vocal fold paralysis without a history of chronic pulmonary diseases and 10 healthy control subjects were studied. Flow-volume spirometry, body plethysmography and tracheal sound analysis were performed within 1 day. The study shows that peak inspiratory flow (PIF) and specific airway conductance (SG(aw)) expressed as percentage of Finnish reference values were significantly lower and airway resistance (R(aw)) was higher among the patients than among the controls (P=0.004, P=0.026 and P=0.004, respectively). The patients had higher sound amplitude of both inspiratory and expiratory tracheal sounds than the controls [root mean square (RMS) values of the power spectra were 31.5 and 25 dB, P=0.006 in inspiration and 31.5 and 26 dB, P=0.013 in expiration, respectively]. Quartile frequencies (F25 and F50) and RMS of expiratory tracheal sounds had significant negative correlation with PIF (P=0.02, P<0.001, P=0.02, respectively) and forced inspiratory volume in 1 s (FIV(1)) (P=0.01, P<0.001, P=0.01, respectively). There was also an association between F50 and peak expiratory flow (PEF) (P=0.02). According to the present study, both quiet breathing and forced inspiration are disturbed in subjects with unilateral vocal fold paralysis. A close relationship between tracheal sounds and respiratory function tests exists.

Breath sounds, asthma, and the mobile phone

The sounds generated by breathing in asthma are widely accepted as an indicator of disease activity. We have investigated the use of a mobile phone and electronic signal transfer by e-mail and voice mail to study tracheal breath sounds in individuals with normal lung function and patients with chronic or exercise-induced asthma. Spectrograms from patients with active asthma and impaired lung function were significantly different from people without asthma (p<0.0001). Our results suggest that mobile phone recordings clearly discriminate tracheal breath sounds in asthma and could be a non-invasive method of monitoring airway diseases.

Acoustic imaging of the human chest

STUDY OBJECTIVES

A novel method for acoustic imaging of the human respiratory system is proposed and evaluated.

DESIGN

The proposed imaging system uses simultaneous multisensor recordings of thoracic sounds from the chest wall, and digital, computer-based postprocessing. Computer simulations and recordings from a life-size gelatin model of the human thorax are used to evaluate the system in vitro. Spatial representations of thoracic sounds from 8-microphone and 16-microphone recordings from five subjects (four healthy male adults and one child with lung consolidation) are used to evaluate the system in vivo.

RESULTS

Results of the in vitro studies show that sound sources can be imaged to within 2 cm, and that the proposed algorithm is reasonably robust with respect to changes in the assumed sound speed within the imaged volume. The images from recordings from the healthy volunteers show distinct patterns for inspiratory breath sounds, expiratory breath sounds, and heart sounds that are consistent with the assumed origin of the respective sounds. Specifically, the images support the concept that inspiratory sounds are produced predominantly in the periphery of the lung while expiratory sounds are generated more centrally. Acoustic images from the subject with lung consolidation differ substantially from the images of the healthy subjects, and localize the abnormality.

CONCLUSIONS

Acoustic imaging offers new perspectives to explore the acoustic properties of the respiratory system and thereby reveal structural and functional properties for diagnostic purposes.

Avalanche dynamics of crackle sound in the lung

We analyze a sequence of short transient sound waves, called "crackles," which are associated with explosive openings of airways during lung inflation. The distribution of time intervals between consecutive crackles Delta(t) shows two regimes of power law behavior. We develop an avalanche model which fits the data over five decades of Delta(t). We find that the regime for large Delta(t) is related to the dynamics of distinct avalanches in a Cayley tree, and the regime for small Delta(t) is determined by the dynamics of crackle propagation within a single avalanche. We also obtain a mean-field solution of the model which provides information about lung inflation.

An acoustic model of the respiratory tract

With the emerging use of tracheal sound analysis to detect and monitor respiratory tract changes such as those found in asthma and obstructive sleep apnea, there is a need to link the attributes of these easily measured sounds first to the underlying anatomy, and then to specific pathophysiology. To begin this process, we have developed a model of the acoustic properties of the entire respiratory tract (supraglottal plus subglottal airways) over the frequency range of tracheal sound measurements, 100 to 3000 Hz. The respiratory tract is represented by a transmission line acoustical analogy with varying cross sectional area, yielding walls, and dichotomous branching in the subglottal component. The model predicts the location in frequency of the natural acoustic resonances of components or the entire tract. Individually, the supra and subglottal portions of the model predict well the distinct locations of the spectral peaks (formants) from speech sounds such as /a/ as measured at the mouth and the trachea, respectively, in healthy subjects. When combining the supraglottic and subglottic portions to form a complete tract model, the predicted peak locations compare favorably with those of tracheal sounds measured during normal breathing. This modeling effort provides the first insights into the complex relationships between the spectral peaks of tracheal sounds and the underlying anatomy of the respiratory tract.

The influence of "sputum-like gel" viscosity on crackle characteristics in a mechanically ventilated porcine lung model

This study investigated the influence of airway secretion viscosity on the characteristics of crackle sounds produced using a mechanically ventilated porcine lung model. Aqueous ultrasonic methylene blue stained gel solutions of viscosity 100, 150 and 200 P were prepared and instilled into 15 isolated, mechanically ventilated, porcine lungs immersed in water. Sound signals recorded by a hydrophone before and after instillation of gel were subjected to both fast Fourier transform and wave-form analysis. At the completion of sound recording, the main bronchi were dissected and the location of the stained gel was photographically recorded. Wave-form analysis demonstrated that expiratory phase crackle incidence and amplitude were both significantly higher than inspiratory phase data. This study demonstrates that crackle duration and amplitude are inversely related to gel viscosity and that electronic lung sound analysis can provide indirect evidence of sputum viscosity.

The relationship between normal lung sounds, age, and gender

Auscultation is one of the most important noninvasive and feasible methods for the detection of lung diseases. Systematic changes in breathing sounds with increasing age are of diagnostic importance. To investigate these changes, we recorded lung sounds taken from four locations in the posterior thorax of 162 subjects, together with airflow. The data were analyzed according to age, sex, and smoking habit. In order to describe the power spectrum of the lung sounds, we calculated mean and median frequency, frequency with the highest power, and a ratio (Q) of relative power of the two frequency bands of 330 to 600 Hz and 60 to 330 Hz. Linear regression analysis was used as a measurement of age-dependence of these variables. Significant differences in Q were found in men versus women (p < 0.05), but not in smokers versus nonsmokers. Within the groups, a small but significant correlation existed between Q and age (r(2) </= 0.1, p < 0.05). For both men and women, a slight increase of the relative power in the frequency band of 330 to 600 Hz was recorded with increasing age. However, on the basis of large individual variations, these small changes (DeltaQ approximately 5%, SD(Q) >/= +/- 5%) have no clinical significance and need not to be considered in the automatic detection of lung diseases by analyzing lung sounds.

Limitations in the use of median frequency for lung sound analysis

The aim of this paper is to investigate methods of standardizing lung sound analysis, with a view to supplementing traditional spirometric air flow measurements to help in the diagnosis of asthma and to provide a measure of the effectiveness of treatment. Lung sounds were measured in nine patients with asthma and five control subjects, alongside air flow measurements of forced expiratory volume (FEV1) and forced vital capacity (FVC). The patients were administered the bronchodilator, salbutamol, to assess how effective these measurement techniques were for quantifying its effect. The results agree with previous studies, that analysis of lung sounds is a potentially useful tool for indicating air flow changes. The results, however, also demonstrate that the emerging standard of 'F50' or 'median frequency' should be treated with great caution because of its high sensitivity to the measurement frequency range. F50 is very unlikely to provide a reliable single indicator of lung condition.

Scaling behavior in crackle sound during lung inflation

During slow inflation of lung lobes, we measure a sequence of short explosive transient sound waves called "crackles," each consisting of an initial spike followed by ringing. The crackle time series is irregular and intermittent, with the number of spikes of size s following a power law, n(s) proportional, variants(-alpha), with alpha=2.77+/-0.05. We develop a model of crackle wave generation and propagation in a tree structure that combines the avalanchelike opening of airway segments with the wave propagation of crackles in a tree structure. The agreement between experiments and simulations suggests that (i) the irregularities are a consequence of structural heterogeneity in the lung, (ii) the intermittent behavior is due to the avalanchelike opening, and (iii) the scaling is a result of successive attenuations acting on the sound spikes as they propagate through a cascade of bifurcations along the airway tree.

Effect of ambient respiratory noise on the measurement of lung sounds

The effect of ambient sounds, generated during breathing, that may reach a sensor at the chest surface by transmission from mouth and nose through air in the room, rather than through the airways, lungs and chest wall, is studied. Five healthy male non-smokers, aged from 11 to 51 years, are seated in a sound-proof acoustic chamber. Ambient respiratory noise levels are modified by directing expiratory flow outside the recording chamber. Low-density gas (HeO2 = 80% helium, 20% oxygen) is used to modify airway resonances. Spectral analysis is applied to ambient noise and to respiratory sounds measured on the chest and neck. Flow-gated average sound spectra are compared statistically. A prominent spectral peak around 960 Hz appears in ambient noise and over the chest and neck during expiration in all subjects. Ambient noise reduction decreases the amplitude of this peak by 20 +/- 4 dB in the room and by 6 +/- 3.6 dB over the chest. Another prominent spectral peak, around 700 Hz in adults and 880 Hz in children, shows insignificant change, i.e. a maximum reduction of 3 dB, during modifications of ambient respiratory noise. HeO2 causes an upward shift in tracheal resonances that is also seen in the anterior chest recordings. Ambient respiratory noise explains some, but not all, peaks in the spectra of expiratory lung sounds. Resonance peaks in the spectra of expiratory tracheal sounds are also apparent in the spectra of expiratory lung sounds at the anterior chest.

Pulmonary auscultatory skills during training in internal medicine and family practice

We conducted a multicenter, cross-sectional assessment of pulmonary auscultatory skills among medical students and housestaff. Our study included 194 medical students, 18 pulmonary fellows, and 656 generalists-in-training from 17 internal medicine and 23 family practice programs in the Mid- Atlantic area of the United States. All participants listened to 10 pulmonary events recorded directly from patients, and answered by completing a multiple choice questionnaire. Proficiency scores were expressed as the percentage of respondents per year and type of training who correctly identified each event. In addition, we calculated a series of cumulative scores for sound recognition, disease identification, and basic knowledge of lung auscultation. Trainees' cumulative scores ranged from 0 to 85 for both internal medicine and family practice residents (median = 40). On average, internal medicine and family practice trainees recognized less than half of all respiratory events, with little improvement per year of training, and were not significantly better than medical students in their scores. Pulmonary fellows had the highest diagnostic and knowledge scores of all groups. These data indicate that there is very little difference in auscultatory proficiency between internal medicine and family practice trainees, and suggest the need for revisiting these time-honored skills during residency training.